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Dare to Innovate: Hepatitis C Models of Care

01:47
Good evening.  Welcome to this evening's webinar on Dare to Innovate: Hepatitis C Models of Care.  This is the third of five webinars in this series sponsored by ASHM.  My name is Michael Burke, I work as a general practitioner in Blacktown Western Sydney and I will be your host for the evening.  To start tonight's webinar, I would like to make an acknowledgement of country.  We recognise and acknowledge the traditional custodians of the land and sea, on which we live and work.  We pay our respect to elders past, present and emerging.  I will now run through a few housekeeping notes.  This webinar is being recorded and will be made available for you in the coming week.  To interact with us today, you will need to use the Zoom control panel.  If you cannot see a panel like the image on the slide, hover your cursor over the bottom section of the shared presentation screen and the panel will appear.  The control panel allows you to select your preferred audio settings and it is where you can ask questions via the Q&A module.  We have put all attendees on mute tonight to ensure learning will not be disrupted by background noise.  As this is a webinar, we are unable to see you as participants.  If you need assistance, please use the Q&A feature to raise any technical issues and to submit your questions throughout the presentation.  Please do not enter any personal information outside your name and question as other attendees will be able to see this.  We will be addressing questions throughout and after each presentation in the dedicated question and answer time.  You can upvote questions by selecting the tick icon on a question.  This will assist you in reducing the amount of same or similar questions being submitted.  Tonight's webinar is proudly sponsored by ASHM and our presenters for this evening are Dr John Smart, Dr Robert Paige and Dr Dr Joss O'Loan.  Our first presenter for tonight is Dr John Smart.  John works in general practice in Hornsby and has dual interests in both primary care and addiction medicine.  He was the foundation fellow of the Chapter of Addiction Medicine and has worked in major teaching hospitals and in the community in AOD, Alcohol and Other Drugs.  John has a very longstanding interest in the treatment of viral hepatitis and AOD teaching in the primary care setting.  Before John starts his presentation, we will launch a poll of five questions, so that all presenters can get a good idea of the audience participating tonight.  Please scroll down the screen to answer all questions.  Just commence filling in those particular boxes and we will get a visual representation of where people are positioned.  New South Wales is doing very well at the moment, ACT is coming up fast on the outside, Victoria is making a good appearance, and if we go down to question 2, we are seeing that roundabout a quarter of people have written a prescription for the direct acting anti-viral drugs, three quarters haven’t, how many patients or people treated, a lot haven’t yet treated a patient.  So, a great opportunity to learn tonight from some very experienced colleagues and then we have got others treating, numbers sort of around 3 to 5 mark.  We are seeing that people have got sometimes there are no outstanding patients awaiting treatment, other times they say a  handful, and looking at people’s perceived reasons for patients remaining untreated, not a priority seeing, and with that I think we will now hand over to John to commence his presentation.  Thank you John.
 
7:00
So, I am just looking around, I have got two versions of my presentation on screen, I must have a look….got the right one, good.  Alright.  Am I good to go here guys?
 
7:44
Yep, you are good to go.
 
7:45
Alright, so, my name is John Smart, I am a GP in the far northern outskirts of Sydney.  I have been asked to talk about models of care in relation to hepatitis C.  Here I am going to talk about a primary care model.  So, I am a longstanding GP, originally trained for rural general practice, which didn’t last very long, and I have been in general practice for about 30 years in the Hornsby area on the northern fringes of Sydney.  For about 20 years, I did a couple of sessions a week in various specialist drug and alcohol settings and I have had a sub practice in my general practice for 30 years of drug and alcohol medicine within a pretty traditional family practice settings.  So, that’s me.  How did I get into this?  Well, I have been talking with Rob tonight, I also really started around Darlinghurst in the 80s, Darlinghurst is deepest and darkest in Sydney and it was adjacent to the completely unreformed King's Cross at that time.  In my drug and alcohol work in the 90s and early 2000, hepatitis C was simply everywhere, and in suburban practice, the incidence was such that I could actually track it moving down peer groups down the streets in individual suburbs as friends contracted hepatitis C from one another in leafy gumtree suburbs in that far north of Sydney.  So, I had a long interest in the evolution of hepatitis C, starting interferon monotherapy and pegylated interferon, an early interest in community treatment, took part in a project in northern area health service in Northern Sydney in the 1990s using just pegylated interferon, and in the early 2000s, combinations of drugs started to emerge.  I took part in education and community treatment parts through ASHM, which I would have to say I am very grateful to that organization.  So, it’s been a long and very interesting journey.  So, I am going to also make a disclaimer here.  I have got the problem that most people working around hepatitis C can’t share, and my patient base is largely cured and it is a struggle to discover and treat new patients.  So, this is what this is about tonight, is reaching out and finding new patients to treat, because hepatitis C over the decades is really a pretty nasty disease and needs to be treated and cured.  So, here’s my very modest medical practice, it’s old, it’s 60 years old, it’s just three associates who just share costs.  These days we are fully bulk-billing in a working class demographic, the suburb is being demolished around us and replaced by high-rise units which are now filled with tertiary qualified migrants, mostly with professional qualifications.  My little practice is currently overwhelmed by its COVID vaccination program.  I am just going to fill it with the screen here a bit.  So, fairly ordinary suburban practice, probably a small practice by current standards.  The drugs and alcohol sub practice… you know, alcohol is quite a large component of this and it’s become more prominent during COVID.  I do home detox for alcohol and opioids.  I have had around about 400 people on OST in this setting over the years, also offer services for prescription drug dependence, other illicits, particularly cannabis, a little bit of amphetamines.  _____ mental health is going to be a big component in this kind of practice, hepatitis C, and within my OST group who are now tending to age, the main thing at the present is to get them to stop smoking, which really comprises a horrendous amount of morbidity, and for them to get established with a GP that’s regular and local and a complement to them, many of these people travel to see me.  So, that’s my drug and alcohol sub practice.  I am pretty selective in my intake, I use referrals from my professional network and also from the user networks.  This area has a bad name, but I found it if I manage it carefully it’s actually a very sustainable and satisfying part of my practice, currently got about 65 people on opioid substitution therapy, probably another 35 on various alcohol programs, most of my patients are treated in pharmacies.  I have had my intake closed recently because of COVID-related stresses in the practice.  Hepatitis C treatment history.  This is fairly typical, we all had large numbers of what we call warehouse to waitlisted patients, who had built up waiting for the fabulous new direct-acting antivirals and once they became available in 2016 or 2017, we treated our warehouse cohort and I had a number of referred patients as well, so we worked our way through quite a large group, and now we are down to a trickle, we believe there’s hundreds of thousands… at least a hundred thousand untreated patients in the Australian community, but we are having a lot of trouble finding [software background noise] them.  It’s important that we treat people because, as I have said and as I will show later, there is a lot of morbidity and mortality attached to hepatitis C as people age.  Now, it’s been a wonderful treatment experience.  Out of my cohort, I have actually had no treatment failures at all and I have got a lot of very happy and thankful patients, it’s a good history.  So, here’s my process, and I am warning you, it’s very low-tech.  So, find and record my patients, assess and treat, and follow up.  Find and record.  Well, obviously the first place I look is my current and semi-current OST group.  I will make sure that people within my practice know and refer their own patients to me, we advertise as a practice website.  I use local GP networks, which might be personal networks or they may be teaching networks or occasionally do pharmaceutical dinner talks.  There is a quite strong user network for all illicit drugs, people talk to one another so that’s a source of referrals and Hepatitis New South Wales has a website that lists treatment, treating doctors, treating sites, participating pharmacies.  So, once I have found my patients I am going to create a ledger and record them and I needed a treatment flow plan because even with the new drugs, initially at least, there was a relative level of complexity.  So I did warn this was a very low-tech approach.  So, this is a part of a ledger that’s recorded all the OST patients I have seen in my area for the last 30 years.  There are number of pages that relate to hepatitis C treatment.  The people that have been neatly inked out on the left are patient names, next column is a series of comments about their workup, the column across the page relates to approval to treat, initially I was using the GESA remote consultation form and a local friendly gastroenterologist who years ago had ____ information.  Starting treatment.  We were doing more bloods back then, so week 4 bloods, week 8 bloods, which include PCR and then the all-important 12-week post-treatment PCR for a sustained viral response, and if you look down here you can see, in my annotations, it’s all clear clear clear clear clear and clear, and once the patients were done and dusted I just put a text through them and I can see it at a glance where I was up to in my treatment program.  So, very low tech, very simple, actually highly efficient system here.  A little bit about testing, so, we are looking for patients, we need to look in high-prevalence groups really, so pretty obviously current and new D&A patients.  There is a group of patients who decide not to get tested for various reasons, maybe they can’t get around to it, they don’t want to do it, or they don’t see the need to do it, because they believed they never injected any drugs, which maybe the case.  My experience is here is that, it can take years for this refusenik group to get tested, but the experiences of the group that doesn’t get tested seems to be at particularly high risk for advanced disease, so they are really worthwhile going after, and you know, there are people that have caught hepatitis C from prison tattoos and other less common means of transmission, which they are not aware of and they are very surprised when they find out that they have got liver disease or infected ____ disease .  So, it does take a lot of persistence, reminder systems on best practice or medical directive are very useful here.  Now, I am happy to take questions, if there’s any questions along the way? In fact I would like to have some questions, because talking to a screen on Zoom doesn’t really give you much sense of what’s going on in my audience.  So, please feel free to put a question up on the checkbox and get it put to me, I’d feel better about it.  So, here’s a testing list, just nothing very remarkable about this testing list.  Once again, anybody with any kind of ID history or appearance or suspicion of ID history, anybody with a history of serious psychiatric illness, particularly younger folks, particularly if there’s been any suggestion of amphetamines involved, anybody out of jail, I have a number of ____ and homeless people pass through the practice, first nations folks, there’s a couple of crisis housing projects in my suburb and I seem to see patients from there and they have a very high prevalence of hepatitis C, so I am keen to test those folks.  Anybody with any kind of abnormal LFTs or… you know, one lady who was cirrhotic who believed her raised LFTs were on the basis of her statin therapy, in fact that weren’t.  Migrants are important to test for blood-borne viruses because they come from high-prevalence areas, both for hepatitis B and hepatitis C.  So, I am keen to include a blood-borne viral testing from my migrant population, but with pretty low threshold.  And other folks, antenatal care patients ____.  Assess and treat.  So, face-to-face, but increasingly with COVID and as my patients get better and scatter, I am dealing with people remotely by various mechanisms, so, lots of telehealths, mostly by phone.  So, I am chasing up by text, quite common to fax prescriptions and pathology requests and occasionally results to distant pharmacies.  Some patients have gone a long way and I manage them by email.   So, this is really not all that innovative, it’s just an extension of what we do in our everyday life to medicine.  Treatment outcome.  I am really happy about this.  Of the 50 patients I have treated, all 48 that I have managed to get followed up have been cured, and actually haven’t had any relapses amongst them either even though a number of them continue to inject drugs.  I have lost a couple of patients to follow-up.  So, it is important, it is not necessary if people would have had uncomplicated hepatitis C that’s been treated and cured, but I like to follow up patients who have reinfections, which is predominantly ongoing injecting drug users, not much relapse of the virus once it’s been eradicated, it’s mostly reinfection.  Cirrhotic patients.  Cirrhosis is not a pleasant condition and it carries a large burden of morbidity and mortality over time and what’s been particularly striking is the amount of hepatoma that I have been seeing.  Now the group that I persistently follow up are people who are untreated but identified, I talk with them ____.  So, a bit of a note about cirrhosis here, cirrhosis is not a benign condition, so in my group of 50-odd or 60-odd folks I have got 14 cirrhotics, I have had five deaths that was cirrhotic related, but there was six hepatomas, three of whom have died, one liver transplant which is hepatoma unrelated and I had two people die of hepatic decompensation, so that’s cirrhosis.  I think in the general practice setting you need to refer your patients on ____ prepared to follow them up fairly persistently and really indefinitely.  Now, a little bit of doubt about hep B morbidity, so hep B is much less common in this setting of hep C.  Nonetheless, I had one hepatoma turn up in a non-cirrhotic hepatitis B individual, a migrant, and this was an incidental finding on CT, and the second one here, this was an OST, buprenorphine maintenance fellow who staunchly and fairly aggressively refused to have bloods taken and eventually turned up one day with a large inguinal hernia and a whole lot of ascites in the scrotum and I thought he had never injected, but the problem was prison tattoos and in fact he didn’t have hepatitis C, he had an aggressive variant of hepatitis B.  So, just a note of caution here really, you do need to impress upon your cirrhotic patients the need for them to have indefinite follow-up.  Untreated patients.  It could be seen as a frustrating group of people, it is common for all those working in this area, so I have got four individuals who I know have got hepatitis C because they have been tested in the distant past, haven’t been able to get them into treatment, I have been pestering them for years.  Mostly they are now distant, and the pestering is done by phone, fax, an example of a couple in the upper ____ I have known for probably 20 years.  They have been busy having a family and of course had reasons not to get the bloods done and get into treatment.  Now that we’ve got telemedicine I don’t see them face to face much, but I am continuing to fax up request forms to their pharmacy.  A couple of office workers here in Sydney, they are now about 50, once again we have known for a long time, they’ve got no veins, they have been pretty wild in their use and so I have got no venous access.  They are busy with their own family, they have got no practical access to dried blood spot testing.  In reality, they just haven’t and I have been cajoling them into treatment unsuccessfully for a decade, and I think there is a high probability that they are going to present with complications of cirrhosis at some point, but what can you do.  Send them off for an ultrasound, get some idea of their liver or FibroScan or ultrasonic elastography can be some reassurance for these people.  So, that’s untreated patients, they are out there.  Some people just don’t want to get on with it.  Lost to follow-up.  Itinerant sorts of folks, in this case first nations folks.  Mobile phones till the numbers stopped working.  Got another fellow in Hong Kong, he is actually a lawyer, but I think he has been involved in heroin trafficking, I suspect he has got quite a deal of legal issues at the present time.  He will turn up in Hornsby again.  I think he is the son of a medical specialist actually.  So, I have been asked to talk a little bit about stigma and discrimination.  I find this a difficult area and I have made some mistakes along the way.  The reason for the mistakes are that I have been dealing with this for so long that I am somewhat numb to it.  So, you know, viral hepatitis, addiction, injecting drug use and psychiatric illnesses, really is part to my medical role that I treat and my patients do well and I am happy with the situation, but it does mean that I don’t always understand how people are feeling about themselves.  So, it is important to understand that patients are very sensitive about this illness because of its connotations, they feel it’s a dirty disease, they feel that they are unclean and it reminds them of events in their past that they had done, that they’d really rather forget.  The patients easily fear rejection, so rejection can come in ways that you don’t really foresee.  If somebody comes to see you, that’s a major threshold event, you may not be in a position to treat them at that time, but you have to be very careful how you express that, otherwise the people are going to feel rejected and angry.  You may have just asked them to come back next month, but they have interpreted this as yet another rejection, so… language is important here and patients are really very sensitive about this illness and obviously, this matter is going to be completely private.  Alright.  Some reflections, so I have been at this for a long time, I think as it has turned out as hepatitis C treatment has evolved in Australia and we are one of the first countries to be able to treat it in primary care in the world.  It’s been a lovey piece of work.  In the general practice setting, what’s made it sweet is it has been simple, bit local, and it has been based around relationships with patients.  Of course, it’s been very successful and it’s been very satisfying for my patients and for myself.  Unfortunately now, I’ve got a low yield of new patients and this practice model is out of time in my setting at least, so we are looking for other ways of doing things.  I do need to have to continue access to high prevalence groups, which means continued intake of people from jail, from marginalised communities and of drug users.  So, that’s my reflection on a long time in hepatitis C in primary care, so … just put this out for some questions if you have got some questions.
 
28:52
Yes.  Thanks so much John.  We’ve had quite a number of questions come through during the presentation, so I’d like to remind people to upvote the questions they really want answered, and I will start off with the first one.  This is a question from Joshua, he asks, have you seen much incidents of reinfection in your patient cohort, would you like to make comments in that area?
 
29:14
Yeah.  Sure.  Reinfection in the broad sense is uncommon, but it really depends on what group you are talking to or dealing with.  So, if you are dealing with an active homeless injecting drug user in the inner city, reinfection is going to be quite common.  If you are dealing with somebody who is stable in treatment or has a stable life and fixed place of abode and a job in the suburbs, reinfection is going to be exceedingly rare, and in the total group, it runs at about 1% per annum or 2 or3 % per annum, but really that’s meaningless ____ which group you are talking ____.
 
30:00
John, we have a question from Paul.  Paul asks do you assess for pre-cirrhotic fibrosis routinely?
 
30:09
Absolutely.  So, look, everybody gets an APRI, most people get some form of transient elastography.  I have had a fairly vexed relationship with my local teaching hospital pathology unit that was much easier to get FibroScans anywhere else in the North Shore for a long time.  I use radiologists to do an ultrasound version of elastography, which gives you the same numbers and give best scores and is good enough for me.  So, I do like to know that.  If the patient is very young, if they are in their 20s, I am probably not very interested, but many patients who are in their 50s and they may have a long history of alcohol use or hepatitis B, so you do need to be aware, but the APRI is a good place to start.
 
30:56
John, third and final question for yourself tonight from Meyer.  What are your thoughts on point of care testing, example the GeneXpert.
 
31:08
So, look, I am in primary care now in a low prevalence situation, so I don’t have access to this and I have had the opportunity to arrange access to it, but really there are not sufficient numbers here to make it worthwhile, so some of my patients would tremendously benefit from this or from dried blood spot testing through commercial pathology laboratories which they can easily access, and so, access to blood is probably the biggest stumbling block for my patients who have not been treated.  So, point care, if I was doing outreach in inner city, that would be wonderful.  In a more stable group of patients it‘s not so important, but I would really like to have my patients when needed to have access to dried blood spot testing.
 
32:08
Thank you John. I will now hand over to our next presenter, Dr Robert Paige.  Robert is a GP and addiction medicine specialist in inner Sydney.  Since 2014, he has worked primarily with populations at increased risk of blood-borne infections.  He has experience in the diagnosis and management of hepatitis C and understands the challenges that hepatitis C virus can present in general practice.  Over to you Robert.
 
32:42
Thanks very much Michael.  Can everyone hear me there?
 
32:50
Yes.
 
32:53
Good.
 
32:54
Wonderful.  Just a moment, I am going to get my sharing screen going ____.  Alright.  Can folks see my screen there now alright?
 
33:12
All good.
 
33:14
Excellent.  Thanks.  Good day everyone.  Thanks very much for joining us and thanks very much John for that, that’s a really great introduction there, really nice to learn from someone who has been working in this space for really really ____ and I have seen the hepatitis C space evolve so much over the years.  So, I am going to talk from my point of view as someone who has been working in general practice in the sort of homeless health and addiction space since about 2014 or so, so it’s sort of seven, eight years or so, so, I started my general practice training back in 2013 and began to look in suburban and inner-city practices first of all and then started working in homeless health in King’s Cross, in the aforementioned deepest darkest Darlinghurst, which is kind of a funny balance between hyperprivileged but also having a really high prevalence of people sleeping rough and people who inject drugs.  And so through that work I started to see lots and lots of people who had hepatitis C and all those people who were at-risk, that is those people who were injecting, and I started to become introduced to how easy treating hepatitis C was, because this was just when direct-acting antivirals, the tablet-only treatment for hepatitis C was becoming available, we were just starting to trial those medications there and I could see that the success rates were enormous, people just seemed to roll through and patients were just so excited by how simple it was to treat hep C after the ____ horrors that interferon had been for so many patients and how much that it scared people away from treatment for such a long time.  I was keen to get involved in that space, both to improve individual and public health, hopefully folks know about the economic modelling that really is very cost-effective to treat hepatitis C over big populations despite the fact that the medications themselves are very expensive and within general practice, in my specialist work, I really like being able to provide comprehensive care wherever possible, that is, if there is an issue, if I can treat it myself, manage it myself safely without having to refer people on, it minimises the barriers to patients.  Patients really really appreciate that and often specialists really like that as well, so that’s why I got involved, and similar with John, so please pop any questions that you might have in the chat box there and I am happy to be interrupted along the way.  This is from back in 2017, so this was only a year or so after hepatitis C direct-acting antivirals became widely available from an article in Australian Prescriber, so I think ____ the majority of patients don’t have severe liver injury and can be managed safely and effectively in the community.  There are some patients with cirrhosis or complex comorbidities such as hepatitis B or HIV and those who fail treatment, back in 2017 absolutely should be managed by an appropriate specialist and even these days I would say many of those patients at the very least want to be talking to a specialist, but back in 2017, a few years back, yeah, we were saying this sort of stuff can be managed in primary care and I think I would absolutely double down on that now, we can do a lot of this.  Like anything, if folks haven’t done it before, it can be a bit discomforting doing something new for the first time, but I guess as someone who started having general practice and still who most of my work is primary care staff, I can reassure you that like it is one of those things that I would strongly encourage you to learn about and get doing frequently if you are not doing it already, and it is for this reason, I mean if you look at this chart, you have probably seen this sort of thing a lot, and maybe it’s… I don’t know, sometimes graphs are a bit of a turnoff really, they can be a bit dry and boring, but back in 2016 direct-acting antivirals became widely available.  At the start, there was, as John mentioned, there’s been backlog of people who had been waiting for the flash new meds and most of them got run through the specialists, you can see the big sort of dark red stripes there down the left, and then as you move along to the right, you can see that the proportion that are being managed by general practitioner is the sort of the …. the beige sort of colour there, has become greater and greater, we are managing sort of roughly a third of the patients around the country and if we can continue to manage those large numbers of people in Australia who have hepatitis C, we are still looking about 120,000 people around Australia who are estimated to have it, they are our patients, the vast majority of them have general practitioners and if we can facilitate access for them to care, I think it’s really positive, particularly if we minimise those barriers.  So, the next little bit is going to about the models of care that I have taken on a bit in the places that I have worked, so that includes general practice in community clinics, standard community based general practices, in community controlled health services and public clinics, so we are talking homeless health clinics, aboriginal health services and in addition medicine services, so I guess the specialist hospital linked clinics.  This is what you get if you search for general practice in terms of a picture, I don’t know why they are like, GPs apparently were always checking blood pressure, I don’t know why GP pictures are always someone checking blood pressure, but yep, apparently that’s what we do, that’s what we love, I don’t know, there’s a little more to it.  This is the place where we worked probably the longest, that’s Kirketon Road Centre or KRC.  If you are ever in King’s Cross and you are looking up at the big famous Coke sign, turn about 90 degrees to your right, that is what you’d see, so, it’s a big old brick building where the Darlinghurst fire station is down the bottom, and above that you have Kirketon Road Center, a public clinic for people at risk of blood-borne infections and people sleeping rough, so we are talking of sex worker, people who inject drugs, at-risk youth and from people living with HIV and hepatitis C.  So, that is the place I worked for a long time, and in addiction medicine as well, again this is what you get if you search for addiction medicine, these pictures always kind of horrify me like the OH&S issues, they are horrifying, not only just the open shot ___ leg, bags of unidentified powder pills all hang in there together, like this is not what people who use drugs will have lying on their bedside table for the most part, like, yeah, people are better organised than that and are less likely to shock themselves.  Regardless, addiction medicine, general practice and public clinics.  So, the stuff in general practice, I mean some of that I think I am rehashing a little bit, so apologies, a lot of it John has gone over really thoroughly there, but I think that the screening part really needs to be emphasised, particularly in populations that sometimes we think might be lower risk.  I do my best to make the habit of asking every person about risk factors for hepatitis C.  I think much more often we have the issue of either forgetting to ask or just not asking because of presumption rather than … yeah, I think more often we don’t ask rather than sort of we ask and we do it poorly.  I think people in general are okay with being asked.  I think some at-risk populations that we sometimes forget to test because they don’t seem necessarily all that important, I guess people who have ever been incarcerated for whatever reason, regardless of their reported history of substance use, it should be tested because even if they haven’t used illicit drugs or injected there is a higher prevalence of hepatitis C within those populations.  As John mentioned, people from countries like Egypt, where they have had these kind of horrible sort of mass vaccination experience with lots of people who have been inoculated with hepatitis C and people on _____ or gay men having condom-less anal sex, gay men having condom-less anal sex should be having a hepatitis C test once per year because while the risk isn’t particularly high there is an identified risk there of potential HIV transmission.  If you are going to be asking about risk factors as well, which we should, sometimes it can even be useful if asked in clusters rather than saying to every person, do you inject drugs or have you injected drugs, saying it more I guess in a fashion of…. also I always check with my patients if they might have any risk factors for hepatitis C.  Risk factor for hepatitis C includes things like having injected drugs, ever having been to jail, having a blood transfusion before 1990.  Do any of those things apply to you?  And that means that people can say, yes, I guess without having to necessarily declare themselves of having partaken in a particularly stigmatised behaviour.  You can unpack it there and that type of questioning has been shown to be associated with I guess people feeling more comfortable being questioned and generally more… I won’t say truthful, but answers that are…. yeah, more truthful answers, let’s say that.   If we are going to treat it, I think we should be able to do that within primary care as per guidelines.  If it is something that you haven’t done I would really strongly encourage you look at ASHM’s two-page primer on how to do it.  It gives you the complete rundown of what to test, why you are testing for, when to test, the sorts of questions you need to ask in taking a history, what to examine, what to treat people with, when to do the blood tests, when to follow them up, even if you don’t learn anything else I think having that at hand is really really useful and it’s a wonderful little resource there, so if you look on the ASHM’s website, you’d be able to find that one.  If we are going to be seeing people, we have screened them, we have done a test there, so ____ doing hepatitis C antibody test and an hep C RNA PCR, if that one is positive and the hep C RNA PCR is positive then we can do things like engage practice nursing staff in the testing, the treatment, the follow-up and the recourse.  If they have got a GP in management plan, getting those additional billing numbers for the nurses to be able to be involved in it.  Some practices that’s relevant and that’s possible, some practices it is less so, but if a practice that I guess is really keen on having nurses do as much as they possibly can inside and outside of ____ health assessments and things like QI projects, they can really be involved in things ____ people and treat them well, and there’s some other projects along those lines that I will talk more about later.  I think prevention is an important thing for us to be involved in too, even outside of screening and treatment, if you are identifying that people have risk behaviours, know about your local NSP, so where people can go and get clean injecting equipment and encouraging people to use those, recommending safer injecting so even if someone thinks they are injecting ____ negative, not assuming any of that and encouraging people to never share an equipment.  Explaining that people can be re-infected even after clearance or cure, which not everyone knows.  If people are using opioids frequently, recommend opioid agonist therapy, prescribe it yourself or refer for it, because that reduces risk behaviours, and one other thing within general practice, I was lucky enough to be involved in this project with ASHM, it was a project that was…I hope it’s okay to ASHM people that are on this call… ____ ASHM projects _____other projects there, I think it will be okay, involving, getting general practices, practice managers, nurses and GPs to essentially audit their patient load for people who have previously had hepatitis C positive tests, both antibody and RNA PCR tests.  So, going through, auditing that, auditing diagnoses, whatever the practice ____ might be, and then doing really intensive recourse around that.  So, this particular project, I don’t think it is running anymore, it is closed, it was thankfully very successful and there were a lot of patients that were able to be linked into care, who were thought to be lost to follow-up, but just really didn’t realise that there were these flash new treatments out there, ____ sure that if you wanted more information about it you can just Google ASHM Beyond the C and the information booklet about it comes up, have a squeeze through and it’s a sort of thing that can be implemented fairly simply in any practice and that, look, I am sure if enough people ____ probably put it on again I think.  One other thing I wasn’t aware of that can be really useful is that if you have got a local pathology provider that you use, you can just ask them to send through all of the results for hepatitis C for patients that you have referred for under the provider numbers for providers working in your practice and just get the positive results back and go through and do an audit that way because sometimes the practice software can be ____ when you are trying to search by those things, so… just some thoughts as to things that one can do with existent systems.  Within the homeless health space… sorry within public clinics rather, so homeless health, community controlled health services, the thing that’s really great about them, I know this doesn’t apply to all GPs, but certainly a bunch of us working in these spaces, I think they can be really great because they lower those barriers, they allow many people usually to go without having to pay anything, if they have got an outreach service in meeting people where they are, so you are being where patients want you to be and again just lowering those thresholds.  If you are heading out to meet people, particularly people who might congregate in certain areas, sleep rough, Aboriginal Torres Strait Islander, patients who might struggle to get into certain geographic areas or clinics, being able to go to them, educate and undertake testing where people are I think it is fantastic.  I will let John speak more about this because this is sort of his area of remit, but yeah I think it’s really great if people are able to do that.  Testing.  I will speak a little bit more about in a moment, but getting access to testing such as GeneXpert, so that clinic on the screen there has one of the GeneXpert machines.  I think they are bloody fantastic, but they are also really expensive.  If you’ve got access to one then I think use it for all it’s worth, but they aren’t everywhere and as I said they are expensive machines, but dried blood spot testing is pretty great, I will talk more about that ____, and once you have diagnosed them, I mean, making sure they are not going to be one of those people that gets diagnosed and then is lost to follow-up forever, making medication simple to access, so helping people by sending their script to the pharmacy or having the pharmacist deliver the medication to their house, or having them pack it up into a Webster-pak, if they are homeless having it available for daily pickup, asking if someone will kindly dispense someone medication for free each day.  Look, if it’s individual isolated cases where someone might really benefit, a lot of pharmacists will get on board with that, or if you know that a patient goes to other services such as homeless shelters, OST clinics, then it can be useful to link in with them just to keep everyone aware of what’s going on with the patient and what can be done to benefit them.  Another really great thing is peer assistance with these sorts of things so, I don’t know what other states have got, so sorry this is a bit New South Wales centric, but in New South Wales we are lucky enough to have hep connect run by Hepatitis New South Wales, so that’s people ____ experience for hepatitis C and having gone through the treatment, providing support for people who just about to go through it, so they have got people who are able to check in via phone and say, yeah, I went through that and I know what’s it’s like, I know it can be tough, but here’s a good reason to stick with it.  It is associated with improved treatment outcomes and people sticking with treatments, so that’s another good thought linking into local peer organisations, because just about everywhere there’s hepatitis peer support network.  The dried blood test that John mentioned a little while ago, so … I think they are body fantastic, they are not available everywhere in every state in Australia, but in New South Wales they are literally available anywhere, because you can go on this website, it you use Google NSW DBS, you can get one posted to any address in New South Wales, this is as a patient you can do the test yourself, you get this fancy little kit that shows up with a couple of lancets, a little card there where you put your five drops of blood, clear instructions about how to do it, and envelope that’s self-addressed, you post it away and you get an SMS or an email or a phone call a fortnight later and it will say you either have hepatitis C or you do not, and so this is a test for hepatitis C viral RNA PCR.  So, viral RNA is not an antibody test, so we are testing do they actually have the infection then… they can also do a test for HIV on the same dried blood spot, they are really fantastic and so, if you are in New South Wales they are wonderful and I would encourage your patients to use them if they have difficulties with venous access.  If you are elsewhere, I am sorry, I think some other states will have access to GeneXperts and dried blood spots in some fashion, probably it is worthwhile checking with your ____ there.  And in the addiction medicine space, so, this is what I am doing most of it at the moment, that’s why this is a bit of a verbose slide, but I just wanted to flag that those people when they have come in and they are talking to you about their substance use issues, just exploring them really in-depth and when someone is coming to ask you about substance issues, especially if it’s illicit drugs, it’s really open the door to being able to talk about ,all sorts of other stigmatised behavior, because they have already brought up something that’s really challenging to talk about, so your door is essentially open to be able to say, look, have you ever have rejected anything in your entire life, have you ever had hepatitis C test, and if so when was it, whether negative, if it was positive have you ever been treated.  I think it’s great to be able to talk about a stuff in the addiction medicine space.  If you have got patients who are on OSTs or methadone or buprenorphine who are picking up daily, then being able to pick up the hep C meds when they pick up their OST can be fantastic, so asking their prescriber or their clinic, can you please dispense their medications at the same time, that can be really a good way to encourage medication adherence.  If you are seeing a lot of people who are at high risk, having things like screening months, say July every year, having all the posters up saying, hey it’s July, it’s hep C screening month, ____ have a test.  I don’t know anything about it.  Oh, well if you have done any of these things at any stage in your life we would recommend you have a test.  Just making it a really easy thing to talk about can be really good.  And the other thing I notice, it is not always easy, I guess I may be see things kind of through rose-coloured glasses because I am both a GP and addiction specialist, but I find that having GPs able to call addiction specialists and vice versa makes things so much better for our patients, so doing our best to make sure the communication is great either way, speaking with your local addiction service and encouraging them, letting them know that you are really comfortable being called about the patients who are known to both of you, I think that can be really  beneficial to patients.  Other things I wanted to briefly mention, finding out from your, local hepatitis clinics if there are any clinical trials going on at the moment, there is always some going on around in inner Sydney and I note that in western Sydney and northern New South Wales, there is some going on at the moment as well, they often provide incentives to patients to have testing and treatment, and they can be interesting, but also really useful both for the patient and for research, and even those little run models of care, say things like in rural or remote areas or in prisons, this one was actually from 2015, so even before DAA's were available, you are talking interferon-based treatment and nurse-supported shared care service where the nurses were doing most of the work in remote Western Australia, they had more than 98% compliance with treatment schedules and so, those people in particular indicated they would delay treatment if it wasn’t available locally.  So, for those people who don’t have specialists local to them, where the patients are going to struggle to go to see a specialist clinic, knowing how to do it or phoning a specialist and saying, hey, I have got this patient, I don’t know how to do it because I have not done it before, can you give advice.  Most of the time it is super easy and specialists will be happy to give you a bit of a hand.  I am going to crack through this because I am mindful of the time.  These are some of the barriers that I thought about based on a couple of trials that I read through and just thinking myself.  I think in particular time pressures is something that is, it’s always difficult in general practice in my experience, and I guess, yeah, people manage that in their own way.  Having tests ____ bloods and the fibrosis assessment, as John mentioned, doing serological or non-invasive and non-imaging fibrosis assessments is really great, so reading the ASHM information about doing an APRI, a serum-based fibrosis assessment or a FIB-4 test, they are really very good at being able to say, look, this person almost certainly does not have cirrhosis and being able to start treatment based on that, and the guidelines recommend that you do that first if you don’t have access to a FibroScan,____.  In terms of getting over the barriers, I think I have mentioned all of these things already, but John mentioned language does matter in these things in terms of reducing stigma, making sure that we are speaking about these things in a sensitive way as possible, and if the patient is saying something and you don’t know what they are talking about, just asking them I guess rather than assuming.  There’s a wonderful booklet that’s called Language Matters, that’s around people talking about drug use, around HIV and around hepatitis C, and I encourage you to read it if you haven’t seen it already.  Just, there are some terms out there that maybe some of us as clinicians might not think is stigmatized, but the patients can find very stigmatising and so knowing what those terms are and what may be to say instead can be useful.  Some people think maybe it’s all a bit ____ but it’s a pretty small price to pay to make people feel more comfortable coming into a health service.  Where people might not know the treatment is now simple, safe, effective and affordable, explaining that to them, if you are ever talking about hep C I think it’s a really great way for people to maybe say, actually I will have the test now, I didn’t know that the treatment was tablet-based and it’s cheap and very effective.  Having resources easily available and patients really frequently want lots of information around this stuff, this is a study there I know lots of ____, this is just from 2017.  Providing individualised feedback about medical results and treatment plans was a facilitator and motivator for patients and getting that information was absolutely critical from patients’ point of view, this is from a survey of patients.  They gave them a better perspective of their health outlook and helped them to feel more informed and in control.  I just wanted to briefly mention a case example from general practice from a couple of years ago, I had a patient in her 50s, she was on methadone for a long time, I had been seeing her as a GP for I think three or four years or so, and I saw her, arranged a hep C test, she was positive, treated her hep C, she was really happy with that, got her _____ treated, got her bilateral knee replacements, her quality of life improved out of this world and through all of that she managed to bring her partner in, who hadn’t seen a GP in a decade and he had hepatitis C as well and he got linked into me as a general practitioner where I really don’t think he would have otherwise, just through the way I guess that we engaged with that initial patient without practice and he unfortunately ended up being diagnosed with cirrhosis and hepatocellular carcinoma, but he is now in treatment for that, so, overall, he most certainly would ____ without ever having a diagnosis, so I see that thing a positive thing.  I will leave some resource out there.  I will stop talking because I know I just blabbered away for 25 minutes and I get sick of my own voice after all so I am sure you are too, but I am really happy to have any questions if there might be any.
 
55:57
Robert, I would like to ask a few questions and encourage others to make contributions as well.  For many of us who are working in this space, we often feel may be a little bit isolated, if you have got any strategies to try and build up a team within your workplace, it’s got an interest in this area.
 
56:21
Yeah, yeah, I mean I think it really depends on where one is working.  If one is working in general practice I have got to say that is where I have felt the most professionally isolated, historically I guess I am lucky that the other practitioner is in my practice in Darlinghurst to have been also interested in blood-borne infections, hepatitis and HIV management, so that helps, but if we are I guess kind of the local champion it can feel a bit isolating, but it can also be impairing in a way because it gives you this area of interest that you can take on, I mean often you will find GPs who have a focus on diabetes or on mental health or on various different things, having a focus on hepatitis C, doing even just a little bit of upskilling can mean that you can disseminate information around that.  If one is feeling isolated and feeling like one doesn’t have enough resources there is just so much stuff out there from ASHM, there are really frequently courses on hepatitis C, diagnosis and treatment, and so I would encourage people to reach out ASHM, get connected to their networks of learning and go along to those courses because that helps a lot, and also contacting the local hepatitis or infectious hepatitis clinic.  I know John mentioned that may be he didn’t have such a good experience with where he works, but, I don’t know, having worked sort of out in the country for chunks of time I have generally found that to be a positive thing to reach out, and often if you don’t talk to the specialists, but phone up and say, hey, can I please talk to the hepatitis CNC, they often love having those conversations because it means that it’s patients that you are managing and they are not getting their books filled up further, so they are just some thoughts, yeah.
 
57:54
And Robert, I would just also ask just a question, can you give us some hints on how to avoid language that’s stigmatising or may close a door rather than open a door.
 
58:07
Yeah, absolutely!  A lot of it is around the sorts of behavior I guess that least people contracting hepatitis C ____ in the first place.  I mean, firstly when someone comes in and they have or are diagnosed with hepatitis C, it is reasonably common I think for clinicians to assume that substance use was the cause for that and yeah, that’s in a large proportion of the time in Australia that’s the case, but there is a significant proportion of people who have contracted it many years ago through blood transfusions, people who might have contracted it through having a fight in prison for example, who have never injected drugs, and while that might be a minority and hey, look, may be what they are saying is true, maybe it’s not, I think assuming that it is related to injecting drug use or maybe labouring the point through much is…. can be significantly stigmatising and overall, maybe not all that useful if it’s a past thing and not a present thing, so I think asking the questions around risk behaviours with an open mind and without sort of… I don’t know … talking about drug use for example, saying, oh, so, when you have had urine test lately, have they been all clean… like sort of talking about drug uses or like absence of drug use is a clean thing ____ having drugs in your urine means the person is dirty, or, so,  have you been using dirty injecting equipment lately, sort of implying that person is dirty by its use, just sort of saying using clean or unused injecting equipment, avoiding language that might imply that what they are doing I guess is bad or deviant or dirty is probably the best way to go.  In particular, I would really encourage you to look at the information that’s out there from folks like NUAA or AIVL, they are sort of peer representative groups of people with a history of substance use or people with blood-borne infections, like HIV AIDS, and that’s got some really good information on this from those people's perspective.
 
60:00
Rob, we have a comment from one of our participants, saying, Robert, your point about language and clustering of risk factors is spot-on to getting through.
 
60:11
Thank you, ____ I fairly use for myself, so yeah, good chance to share that.
 
60:20
Thanks Robert.  Our final presenter is Dr Joss O'Loan.  Joss is a GP and co-founder of Kombi Clinic.  When not working at his usual gig of Medeco Inala General Practice, he is driving around Brisbane in a 1975 yellow Kombi van testing, treating and curing hep C in a variety of locationsThanks Joss.
 
60:40
Many thanks Michael.  Thanks very much ASHM and RACGP for hosting tonight.  It’s always fantastic I find.  Sharing the passion of hep C elimination with other GPs, it really is the case that GPs are up to the task and up to eliminating hepatitis C in Australia and that’s really exciting for me, so it’s great to have the opportunity to talk about what I am very passionate about and what I am sure everyone here is very passionate about, hep C elimination within this decade.  So, just a GP, just a Kombi, just hep C elimination.  Also I acknowledge, just to start, I am speaking to you from Jagera and Turrbal land and pay my respects to elders past, present and emerging.  I will talk a bit about Kombi Clinic in a biz and so I should also say that we get a lot of help from our friends, to name but a few, special mention to John Conroy, he is our mechanic and if you have a 1975 Kombi van, you get to know your mechanic very well, so a big shout-out to John.  The first part of my talk tonight, talking about my regular GP Clinic, so … a bit similar to John who spoke earlier this evening, I work in a regular run-of-the-mill general practice as my usual day job.  It’s in Inala which is sort of the Mount Druitt, Brisbane or Sunshine if you are in Melbourne, so that kind of socio-economic environment.  It’s a fairly usual sort of general practice, ____, all these and the like.  There’s five GPs that work with this, including GP registrars.  Because of the demographic and where we work, there’s a lot of people who inject drugs.  As a sort of the component of that, if you work in an area of people who are injecting heroin, prescribing methadone and Suboxone makes sense.  So, myself and another GP Matt Young.  We have about 200-250 people on our books at any one time and that obviously rolls through.  So, that’s where we work.  Back in 2016-2017, at the dawn of this DAA revolution, as John and Robert have been saying, that the DAAs have come about and really transformed the way that we treat hepatitis C as those bar graphs show.  We got on the front foot and we offered hep C testing to rule out patients.  We had about 226 hep C antibody positive, 38 who had serologically resolved themselves, leaving a 188 hep C RNA positive.  The way we have gone on and sort of did that was using a lot of the strategies that both John and Robert was talking about.  Now, really normalising the conversation, look we do this for everyone, this is just the test that we do, how do we get it done and by the way, even if it’s positive there’s a really simple treatment for it.  Normalising it, simplifying it, making it really simple, and having posters up in the waiting room.  It became the usual conversation that we would have with our patients.  Of the 188 that we had, 25 we referred onto to tertiary care, a 133 were treated by us, and about 30 had moved on or got into jail or lost before we could actually start them on treatment.   At that time, like John was saying, we use that sort of gazette guidelines and had really good relationships with gastro, ID colleagues at the local hospital and again, following on from the previous people I would really encourage if you are starting out and I think there’s a few people in that questionnaire at the beginning who said they have treated one or two or haven’t treated any.  Now, reaching out to your local gastro or ID department is a fantastic way.  I probably echo what Robert was saying, often the CNC in the department is probably a really good person to chat to that will give you a great answer and in terms of logistical flow, usually be able to sort of work out where we are going.  So, in terms of the 133 that we put onto treatment, 10 were lost to follow-up, 4 were failures and they were unfortunately all due to non-compliance and 2 re-infections, which we had subsequently got back onto treatment.  In terms of general practice, and I assume a lot of people on the call tonight, GPs and sort of run-of-the-mill kind of places, and this is all a bit too hard kind of feeling, was definitely what we were thinking back in 2017.  But really our patients are core demographic that we see and again to echo from Robert, the thing that we sort of hold here as a GP is look if I have got the skills to be able to treat you in my GP practice without referring on then I will, and a lot of these patients are really suitable for general practice.  So, 85 had an APRI less than 1 and so that’s that calculation using liver function and platelets, which shows that I didn’t need to go on and get a FibroScan or elastography or anything fancy along those lines, a simple blood test was going to tell us whether they were fibrotic or cirrhotic and ____, so that was fantastic.  No HIV and no hep B coinfection, so that’s obviously demographic.  There was no one that we needed to involve their ID colleagues for and sort of move forward.  But also really importantly, these are our patients and getting back to that point that we are talking about, they trust us.  Stigmas are a really big issue with a lot of patients who are injecting drugs and a lot of patients who have hepatitis C, as Robert was saying, there is often a ____ between the two of them, Oh you have got hep C, therefore ____.  These are our patients, they trust us, they have opened up to us, they have told us the story, and I don’t want to go on and tell a gastro and ID and unfortunately the stigma of that heading into a tertiary hospital makes it really hard.  So, getting on and cracking on our patients was something we held dear.  We had a lot of learnings from eradicating hep C in our practice and I guess the first thing to say, it’s really really simple, especially compared to other aspects of being a GP.  I am not sure what other people on the call are like, but there seems to be umpteen new diabetes medications, every second week there’s an asthma puffer that comes out, it’s a slight different shade of purple, that therefore means something something something, and trying to get your head around that compared to hepatitis C, there’s no competition, it’s a straightforward testing algorithm.  Again, plugging ASHM sort of guidelines, it’s really quite simple, really quite basic and simple treatment options.  You know, these days we are really left with two medications to choose between, both having just as great efficacy as each other.  Also, what John and Robert sort of touched on, hep C is extremely rewarding.  To be able to tell your patient, hey by the way, you are cured, is fantastic.  Now, the hugs, the kisses, the handshakes, it’s an amazing experience for often these patients have gone around, for decades often, with this feeling on their back of hep C and all that that involves.  Many had sort of lost the injecting drug behavior many many years ago, but they are still left with this hep C, it’s indelible sort of marker on them or a tattoo that’s forever there.  To say, hey by the way you don’t have hep C is a huge thing and as a GP, we don’t get to ____ much, that’s a really huge rewarding thing to do in your career.  Barriers for patients to access care was also something that we realised was really huge.  Hep C is no longer a medical challenge.  Hep C is ____ straight easy, line them up knock them down type approach to treatment.  It is a social issue at the moment really, hep C in Australia.  Finding people, getting people onto cure, onto treatment, you are solving those social issues, and again, that’s why GPs or general practice is so well placed in treating patients with hep C, because we can provide that wraparound service, you can give that mental health, you can give that addiction medicine treatment and all those other sort of aspects that we do so well, so I think that’s really important.  And also stigma, stigma is a huge issue as everyone sort of touched on tonight.  So, we ___ drive a Kombi van, break it down, talk to them on their level.  If you have got a patient who is a Bintang singlet and started using one broken thong, they of course are going to feel stigmatized because we have to tell them to go up to the third floor of a public hospital with someone with a tie and a suit.  Now, they are not going to go, because they don’t want to go.  So, you need to bring the treatment to them, and this is what we sort of learned.  The other thing that would probably [software background noise] _____ is working… you know I work in a windowless box in a general practice, there’s no window, so I thought… the other learning is, I’ve got to get out, I’ve got to get out of this windowless box, and so the solution of course is a Kombi van.  The cure must be taken to the people, breaking down those social issues, breaking down those barriers, and really simplifying the process.  So, Kombi Clinic has been operating in south-east Queensland since 2007 and the Kombi is iconic.  It’s a fantastic vehicle when it starts and when it gets there, it does open that conversation, everyone seemingly has a story about a niece or a nephew or an uncle that drove up the Hume Highway or got stuck in Lismore and out the back of Bourke and then it burnt down, so it’s a great way to just spark up a conversation and then you go, mate, by the way, how about we have a yarn about your hep C or about injecting or ____.  We have got a philosophy in the Kombi Clinic and myself and Matt, that there is no such thing as a hard to reach patient.  If you are describing your patient as hard to reach then you have lost the thought.  It’s the doctor that’s hard to reach.  Again, if you are homeless, if you are injecting drugs and someone says, hey, here’s an appointment, turn up to this and then I will refer you to another appointment and if you miss that appointment then I will never see you again.  That’s a system that’s not going to work for a lot of people.  We need to change our service, we need to change our model of care to fit into the patient and not have the patient try and squeeze into our model of care because a 9-5 ____ is good for us, because that’s not going to get the patient treated.  If you are not getting winched out at the side of a helicopter on a mountain, you can’t describe your patients hard to reach.  Or putting it in another way, if you invite 20 friends over to your house and none of them show up, maybe it probably says a bit more about you than it does about your friends.  So, you know, I think making the model of care fit the patient is really important.  Or another way that we like to think about ourselves is ____.  I know this is always a tricky slide to put up this time of year, especially considering ____ in Queensland.  We got wiped out a couple of weeks ago, but I like to hope, I like to think back of the good times and there’s a couple of games left to go, so this is how we work.  So, the specs of the Kombi Clinic, the important things, 1975 VW bi-window, we have called it Lucy Sunshine.  So, far we have had a couple of RACQ tows.  Medical students are really important to come out with this, not necessarily for a learning ____, but mainly because we need a push start halfway through.  Hill starts require meticulous route planning and OH&S means we will have to get serum lead levels every four weeks.  The team, it is a pretty small team, there’s two GPs, we have got the best nurse going around and a fantastic phlebotomist Mick.  We are pretty small, looking for franchise opportunities like ____ we are going to have Kombi Clinic franchise out there, so drop us a line.  But again, we were allowed Hawaiian shirts ____ tonight, we play music, we have got a laidback vibe, encourage people to come in and chat to you, and that’s sort of it.  Coming back to the ____, I can’t get a Kombi, I work in a GP, how do I incorporate that into my general practice.  Having a laidback vibe, having a no-stigma approach every time you are talking to someone about drug and alcohol abuse, having a no-stigma approach is same way you chat to someone about whether it’s domestic violence or mental health issues or any other infectious disease, chlamydia, gonorrhea, HIV.  Approaching this in the same way than you would ever anything else and allowing the patient to open up and have a yarn to you, that’s really important.  Make it simple, make it fast.  Hep C treatment as I said is not rocket science anymore and make it really easy and reduce the effort that the patient needs to go to, and that way you can bring up their priorities.  So, on Kombi Clinic, they speak to a GP or my daughter, depends who is around, they get a blood test and we also have a FibroScan, so we are pretty fortunate in we have a FibroScan.  A lot of people that I speak to, these sort of gigs, we need to get a FibroScan, need to get a FibroScan.  You don’t.  You only need to get a FibroScan if there are other markers that are ____ and APRI as I showed before is going to rule out cirrhosis and fibrosis in the vast majority in 9/10 of your patients, but we are just lucky to have a FibroScan.  We usually use it more as a gimmick for a lot of patients, hey, come over here I will show you instantly how healthy your liver is and they are interested in that and we can then draw them into a conversation about hepatitis C, about alcohol use, about drug and alcohol and then those kind of things and so it’s a really nice conversation starter rather than sort of a diagnostic tool, so that’s where where we are.  After that, we sort of arrange follow-up, so the bloods … with Michael, you don’t go off to a commercial lab and then sort of the turnup is sort of two weeks later.  So, we talk about where we are going to be and how we are going to follow up.  So, the traditional Kombi method and we will sort of talk about the new Kombi method, but this is the traditional.  So, we have a chat, we have a FibroScan, we do full bloods, and that all takes about 20 minutes.  A lot of patients that we see are usually young, fit and healthy apart from hepatitis C, and so that means that a medical consult is relatively easy, the medication list is usually relatively short.  Traditionally, we come back to the same venue every four weeks, so we sort of have a rolling roster, once or twice a week we will go to a new place and we will then ensure that we are back to the same place every month and we can then follow up with patients, so we give out cards and phone numbers and Facebook and Instagram and ____ we get their details ____as you would and a usual GP consult.  We turn up, if they are hep C negative, we have a chat about ____ injecting drugs, we have a chat about using unused, clean or sterile gear, we have a chat about how often they should get tested, and if they are hep C positive, we would link them into care as rapidly and quickly as possible.  Those that are at high risk, so a small minority, we link off to our colleagues and their hospital, but the vast vast majority we can treat as well.  We give them a supermarket voucher as reimbursement for their time, often these patients have sort of come in, caught a bus or taken time out of their day, so to acknowledge that effort they have made we given them a 10 or 20-buck voucher.  Or so, as Robert was saying, getting them to bring in their friend is also really important, you know… the husband, the wife, their injecting network, it is really important to treat them as well.  So, just in the same way that if you tested someone positive for chlamydia, you’d say, hey look I’ve got a tested partner too, if you test positive for hep C we really encourage, hey bring your injecting network in, we will cure everyone and that way reinfection rates dramatically drop off.  Follow-up in the telehealth age has been real boon, so we can then get on the blowup, we can call people, we can nag them, have you got your meds, are you taking them all the rest of it.  So this is the two-step process.  And again, relating it back to, if you don’t drive around in a silly van, how do you do it in a general practice.  Trying to streamline things as quickly and as efficiently as possible, not making people drive all around the city trying to get different bits of investigation, making it streamlined and simplified.  Where does Kombi go?  We sort of go all over, anywhere that we reckon is going to be a pretty good uptake in terms of hep C treatment.  So, we go to drop-in centres, day centres for homeless people, shelters and hostels, we got a different government-run drug and alcohol clinics, homeless events, a couple of music festivals which you could ____, we have been to a few jails, community corrections or probation parole.  We go to other GP clinics and aboriginal medical centres, anywhere that sort of encourage us to come in and we test treatment cue up as simple as possible.  So, the stats, we have seen up until late last year and it’s just me being lazy in terms of haven’t crunched the numbers again in the last six months.  We were seeing quite a significant amount of people and a lot of those antibody positive.  So, that 30% of people we see are antibody positive, so that’s compared to just about less than 1% of the population in Australia having hep CThe numbers don’t quite add up, we are doing some fingerpricks testing, so that’s why the numbers are a little bit out of whack, and I will talk about fingerprick a bit.  RNA positive about 19%, so, again we are sort of going to the right targets.  We know where patients with hep C are, there’s some really good studies from Kirby and Burnet about modelling where the hepatitis C patients still reside, we have sort of taken it on our back rather than waiting for them to come to us, hey let’s go out and get to them.  That 81% of patients requiring a script for hep C, we have been able to get a script to.  Lost to follow-up is a bit of an issue, a lot of patients have no mobile phone, have no postal address, they are sleeping rough, so to try and get six months after for that SVR data is quite challenging.  But what we know is that if you can reinforce and if a patient can take a tablet every day for two months or three months, whichever treatment hey are going for, then cure rate is fantastic, so 95-plus percentagewise.  So, we are not too fast.  We are not going to knock start a patient on hep C treatment because we can’t follow them up in six months.  We know that if they can take the medication then they are cured and that’s pretty all.  Talking about point of care, so Rob talked about dried blood spot and I will talk a bit about Genex or GeneXpert, someone also asked about before.  Look, if DAA's were the first revolution, I think point of care testing really is the next revolution.  It is fantastic.  It is able to diagnose an RNA of a single fingerprick avoiding the need for venous access, which is often a significant barrier for a lot of people with an illustrious history of injecting drugs, so just being able to do it off a drop of blood like you would for a blood sugar level is brilliant.  You get the result back in an hour and it is quite simple, quite easy to set up, patients love it.  It is TGA approved last year, which means that you don’t need ethics and you don’t need research projects and all that kind of stuff, but it’s not yet Medicare rebatable and that’s sort of the kicker.  Hopefully, that will come, we have seen HbA1c's get a rebate for point of care testing recently, and so hopefully more point of care testing will get on the Medicare rebatable system, which means that these kind of tools will be far more useful.  I agree with John at the beginning, you picking your target audience for something like this, you don’t set up a GeneXpert at the kindergarten ____ and expect high throughput.  Setting it up at a place where you are going to get a high rate of people who have hep C is really important.  So, at our general practice, we have got a large population of people in and out of jail and a large population of people still injecting drugs, we are still getting 10-15% HCV RNA ____, which is great.  But hopefully Medicare comes on board, write to ASHM, write to your local NP and ask them for ____ it’s only way we will probably get it there.  How do you do it?  Again, just the slide showing how simple it is, to click on the finger, it’s a little bit of finicky around drawing up the blood through a little pipette thing.  You stick in a cartridge that looks like a wheelie bin, stick in the machine and an hour later you’ve got your results, and it’s as good as any commercial lab going around except you can stick it into backpack and off your way.  A lot of commercial labs actually use GeneXpert for all these tests.  Interestingly, also the usability of GeneXpert, so it’s been used throughout Australia for a lot of different things, that’s the cartridge that changes the test, you can get gonorrhoea, syphilis, TB tests to name but a few.  So, they are using these all throughout Australia and have done for years and years, so it’s quite a wide use test, hep C is ____ to marker on that.  In terms of point of care testing that we have seen, so, we have had it up and running since November 2020.  We are using it in our general practice and also out on the road with Kombi.  So, we have screened almost that 300 patients, and again, it is a bit lagging in terms of the results.  The vast majority are RNA negative which you would expect to see, but 44% are positive, so, again, we are getting significance of a target market in terms of people who are seeing.  Just in terms of the GP, clients that we are seeing, we had about, of that 44, we had only 12 of those positives for my general practice, six were brand-new, never diagnosed before, those six were waiting for something like this to come along, so those six knew they had hepatitis C, but for love of money could not get blood out of them.  Ultrasounds wouldn’t do it, femoral taps couldn’t get it, so the only way we could get them onto treatment was by this RNA, so that was revolution for them.  The other six that we had or thereabouts were actually reinfections, so… our reinfection rate was quite high than we thought it otherwise would be, so, 5, 6 or 7% and that’s probably an onus on us, that we weren’t testing more regularly, but just an indication that they are having something as simple as a point of care testing means that regular hep C RNA testing can occur and is quite a low barrier for it to occur.  The other important thing that we found is the speed in getting patients onto tests or onto treatments.  So, about 42% were able to start treatment on the same day that we gave them the diagnosis, which obviously has a significant benefit for the patient, you tell, hey, by the way we think you’ve got hep C, but we are going to wait a bit until we get the diagnosis, then we will start tests and so, the anxiety for a patient is all removed.  You have got a disease, here is the treatment, three months two months you’d be done, and the 84% were done within a week.  Also important use for point of care in this example is getting that SVR data or serum response at the end of treatment to prove they are cured, so we had about 13 of the negatives were actually cured patients, which is great to say.  The Medeco Inala, we don’t just do qualitative, we also do quantitative or other way round ____ research, but just to show patients really love this, and similarly with the dried blood spot as previously it was spoken about, simplifying the test, bringing the solution to the patient rather than the other way round is what it’s more about.  We are being fortune enough to get up a couple of prisoners as well, so again, using the theory of taking the treatment take the cure to the patients, so running some treatment testing blitzes at a prison, testing the entire prison over a couple of short days.  Point of care means it is now feasible teamed up with some great colleagues in Queensland, so corrections and Queensland Health sort of reformed the team and now went to a couple of joints, and of course for Lucy Sunshine along as well, so this is us at a low-security prison called Palen Creek, which is just on the New South Wales border, which was fantastic, it was a great experience.  Another photo showing the importance of teamwork, at Palen Creek they have got a 165 people residing there or inmates, we were able to test 161 of those within three days, starting all those patients requiring treatment on the same day of their diagnosis and also dispelling myths as well as we sort of went along.  So, a lot of people were unsure or had been using or still using in jail so to speak ____ and able to say, hey look now you are fine, so that was really important.  We have done Brisbane Women's Correctional Centre, so another sort of a larger prison, so 240, we did 200 of those, that was over four days and Helana Jones which is a smaller community-based correction centre for women, ____ kids or breastfeeding or whatnot, so we did the launch ____, but just setting up a treatment blitz program is really possible, and again bringing it back to general practice, as Rob was saying, having a month, having a week every… we are going to test everyone this week or having a blitz as we run through really normalising the process, and if anyone on the call does work in corrections, having to think about how to tackle hep C elimination within your prison or within your jurisdiction I think is really important.  Just to finish off, as I have been rambling on… hep C cure means a lot to a lot of people, it’s not just numbers on a page, it’s just not a bar graph or a cascade of care and I think it’s really important to acknowledge that and to think about that.  So, back in 2019, in the pre-COVID era, we handed out all our patients that were started on treatment, those old disposable cameras you ____ and click and said, hey, look, document what hep C means to you and take some photos, and so this is a couple photos that we got from that photo exhibition (long pause).  And I particularly like the last one, just that vista looking out, that freedom, freedom from hep C, freedom from the risk of cirrhosis, freedom from HCC, freedom from that stigma, ____.  Thanks very much for having me on board.
 
90:00
Joss, thanks.  We have had quite a few questions come through during the presentation.  So, I would like to remind people once again to upvote the questions they really want answered.  I will start off with the first one.  We go.  From Ristow, who is funding all this in the Kombi Clinic?
 
90:19
Fairly hodgepodge to begin with, so we started off… having an idea is the most important thing, so we had the idea and we sort of ____ and then we worked through money as we would go from there, so we string from grant to grant to grant.  We started off with a grant application from NSD, who are longer in the market, and so we linked in with Hepatitis Queensland and so our local org, and MSD were able to fund, Hepatitis Queensland who were able to fund us, and the PHN over the years has also been quite supportive, that sort of funded us for a year.  The Queensland Government also for the last three have sort of given the lion share, but also then community grants, so ____ grant for anything just to try and get some money to try and continue along.  But a lot of love and time and effort goes into it.
 
91:23
Joss, another question.  How expensive is point of care testing? Is it viable to have it, say, headspace centres?  I think there are 100 or so headspace centres nationwide.
 
91:38
Yes.  Well, yes and yes and yes.  Like I said, I used to work at a headspace centre for about six years or so, and it would depend on the demographic of that headspace centre, but I think having a point of care test in a headspace centre would be fantastic if that demographic has a high rate of injecting drug use.  Where I worked at Woolloongabba, which is sort of in a city, there wasn’t quite a bit of drug use associated with it, but there was lot of pills and smoking rather than injecting.  So, again coming back to John’s point, if there is a need to do it.  Cost analysis.  I guess it depends on who is paying the cost.  From a public health Australia-wide point of view, yeah, definitely, there is a huge call for it.  So, for every one dollar spent on hep C treatment and diagnosis, we save 4 or 5 in the long run.  Hepatitis C cirrhosis and HCC is not cheap to treat.  So, yes, there is, to answer the question a bit more directly, the machine is about 30 grant, each test is about 70 or 80 dollars for RNA.  In terms of Medicare rebate, so if you speak to your private pathology guy, they will be getting about, correct me if I am wrong, it’s somewhere about AUD150 from the government from Medicare rebatable service for running a hep C RNA test.  So, if it wasn’t Medicare rebatable service then there is obviously a buffer there.  There’s a few barriers to jump over in terms of making it Medicare rebatable, the first one is Medicare want you to have antibody before you have an RNA.  If you are just doing point of care, there is none, ___ work that out later, and also all that lab work and all that kind of stuff to make it Medicare rebatable, but the short answer is look, I think you can’t spend money on hepatitis C and lose it, any money you spend on saving someone's life or having a long history of prolonged illness, in a public health sense you are going to be saving money in the long run.
 
93:54
Joss, I just acknowledge and thank Nicole for that last question.  Next question comes from Ristow.   It’s about a question about advertising.  Is it acceptable or legal to advertise medical services with giving away supermarket vouchers?
 
94:11
Good question.  So, well I guess the idea behind reimbursement or behind incentivising treatment is quite …  there’s a long history of incentivisation and reimbursement of services for anything, and I think probably comes more down… is it legal, look, I don’t know if the Queensland Government wrote a law and passed and said, no, you can’t do it, or the Australian Government.  It’s done, Kirby Institute do it, Burnet do it, lots of people do it, so I am sure it is legal.  Is it ethical?  Look, I think it definitely is ethical.  It is about where we are putting our value and how much value do we put on our patients, and I think if you can say, hey, Matt, come over here I will do a hep C check for 10 bucks, look, I have got no qualms with that, if I am saving his life, and again, looking at a public health situation, if you are preventing him from passing on a potentially deadly disease to five, six seven other people, you are creating a greater public good.
 
95:24
Great Joss.  Two questions to go, question from Meyer, starting treatment the same day as diagnosis sounds ideal.  How many of the 42% who started treatment the same day as diagnosis finished treatment?
 
95:36
Oh, okay ____, so how many of those have gone on it and finished.  So, the answer is, we are not sure yet, so that data was from November till now, so we are just coming into that six months post-treatment SVR sort of range.  I wouldn’t expect it to be any different to what we are seeing already and that is that we are getting sort of intention-to-treat data of SVR about 96%, so I wouldn’t expect it to be any different.
 
96:12
Thanks Joss.  ____ question from John.  What was the RNA positivity rate for the corrections cohort?
 
96:20
Really interesting.  So, at Palen Creek, we had, of the 160 odd, we had three people positive, which was quite interesting ____ think about that, Palen Creek being a low-security beautiful beautiful prison.  If you have a need to go go there.  There is no fences, so that said, it is a 2-foot high fence that’s falling over, and that is pretty much the fence.  So, what the guards were telling us is that a lot of people obviously using injecting drugs, but when they get their drugs thrown over the fence, the 2-foot high fence, they also get a swag bag full of clean needles, so, in this prison they have got a peer run harm minimisation resource of clean, sterile injecting drug equipment.  So, that’s fantastic isn’t it?  Unfortunately, the prison guards, they showed us the bags that have confiscated, like…. Ah, why did you confiscate them, that’s right… but yeah obviously that’s what we have to do, but so, potentially it’s because of they are running their own needle syringe program in there.  The women's prison was a bit higher, so that was about 10%, which is what you would expect, that was a moderate medium-secure prison, so that’s probably what you would expect, and at Helana Jones where there was only 20, those 10% we had two or three pickup there.
 
97:50
Thanks Joss.  Great presentation.  Two comments.  Comment from John, he would like to reinforce the isolation for drug and alcohol work in primary care, it is very necessary to maintain professional links in this type of work, local CNC, local drug and alcohol person, other colleagues.  One important comment, Robert has shared, as mentioned The Language Matters resource is available, I have just googled it on my mobile phone and it’s the top one that comes up, so it’s two pages of some excellent language to use and some other languages that are better avoided.  So, I am afraid that’s all we have time for this evening on behalf of our webinar partner ASHM, ASHM of course is the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine.  We thank you very much to everyone for attending and we hope you enjoyed the webinar.  Also a big thanks to our presenters John, Robert and Joss for sharing their knowledge and time this evening.  We hope to see you all for the fourth webinar of this session series, Hepatitis C in Primary Care (Queensland) on Wednesday, 14th of July.  This webinar is intended for Queensland participants only and will be slightly geared towards Queensland, but we would still welcome participants from other states.  Good night and a great evening.  Thank you very much.

 

Other RACGP online events

Originally recorded:

22 June 2021

The Australian Government has endorsed the World Health Organisation targets of 90% of people living with chronic HCV infection to be diagnosed, with 80% treatment coverage by 2030. Since the introduction of interferon-free direct acting antiviral (DAA) therapy on the Pharmaceutical Benefits Scheme in March 2016, an estimated 70, 260 people have been treated in Australia.

Australia is a world leader in progressing the elimination of HCV as a public health threat by 2030. A key feature of the Australian HCV treatment landscape since the DAA program commenced has been the involvement of non-specialists in prescribing.

Join Dr Joss O’Loan, Dr John Smart and Dr Robert Page for this interactive webinar that will explore innovative models of care with the aim to reinvigorate general practitioners’ engagement in prescribing DAA therapy for hepatitis C. After attending this webinar, attendees will identify patient barriers to testing and treatment and consider new strategies for connecting with the patient population to find and treat the remaining cases in Australia.

Learning outcomes

  1. Become aware of successful HCV models of care in Australia
  2. Identify patient barriers to HCV testing and treatment
  3. Consider new strategies for connecting with the patient population
This event attracts 3 CPD points

This event attracts 3 CPD points

This event is part of ASHM Series. Events in this series are:

Facilitator

Dr Michael Burke

Michael Burke works in Western Sydney GP. He is committed to improving health equity, treatment and care for people with blood borne viruses including HIV. He works in whole person medicine framework, and enjoys getting to know his patients, reading, writing, and birdwatching.

Presenters

Dr John Smart
General Practitioner, Addiction Medicine Specialist, Asquith Medical Centre

Dr Smart works in general practice in Hornsby and has dual interests in both Primary Care and Addiction Medicine. He was a Foundation Fellow of the Chapter of Addiction Medicine and has worked in major teaching hospitals and in the community in AOD. John has a very longstanding interest in the treatment of viral hepatitis and AOD teaching in the primary care setting.

Dr Joss O’Loan
General Practitioner, Kombi Clinic & Medeco Inala General Practice

Dr Joss O’Loan is a GP and co-founder of Kombi Clinic. When not working at his usual gig of Medeco Inala General Practice, he is driving around Brisbane in a 1975 Yellow Kombi van testing, treating, and curing Hep C in a variety of locations

Dr Robert Page
GP & Addiction Medicine Specialist

Rob is a GP and addiction medicine specialist in inner Sydney. Since 2014 he has worked primarily with populations at increased risk of blood-borne infections. He is experienced in the diagnosis and management of hepatitis C, and understands the challenges that HCV can present in General Practice.

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